Beneficiary Challenges in Using the Medicare Part D Appeals Process To Obtain Medically Necessary Drugs

This paper describes the various steps of the Medicare Part D appeals process for obtaining necessary drugs not on a plan’s formulary. Using case reports collected from a network of beneficiary advocates, it illustrates the challenges and problems some beneficiaries encountered when navigating this aspect of the drug benefit. The paper concludes with a discussion of potential policy options including the implications of establishing an exceptions and appeals process that is uniform in paperwork and procedures.

This report was prepared by Vicki Gottlich of the Center for Medicare Advocacy, Inc. It was commissioned by the Kaiser Family Foundation to provide insights into Medicare beneficiaries’ experiences with the Part D appeals system from the perspective of legal advocates who represent them. The problems described in this report are examples of problems encountered by a number of beneficiaries, but should not be construed to apply generally to the Medicare population. The views in this report are those of the author and not necessarily those of the Foundation.

Issue Brief (.pdf)